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Winter 2002 Newsletter

On-Line Newsletter Volume 1, Number 2
Published December 4, 2002.

Edited by Chaplain John Ehman, Network Convener

Editor's Note: Network members are encouraged to submit articles for upcoming issues of the Newsletter, is published three times a year: Fall, Winter, and Spring (but may be published more frequently in the future). The Spring issue will be posted on the site in April 2003.

Table of Contents

  1. Call for More Listings on the Current Research Initiatives Page
  2. Report of Original Research by Network Member Dick Tibbits
  3. Web Finds: Research-Based Presentations On Line
  4. Student Guide I: Thinking Critically about Questionnaire Items
  5. Convener's Report


1.     Call for More Listings on the Current Research Initiatives Page

[NOTE (added 2/1/07): The Current Research Initiatives page is currently removed from the website for revision.]

The Current Research Initiatives page of this web site covers announcements of research-related activity across the ACPE and in that regard is at least as news-oriented as this Newsletter page. Listings are not be only about original research but about the use of research in CPE curricula, in quality improvement projects, and in education evaluation. Supervisors are asked to send brief notices for the posting of activities at their centers. The listing can be an important source for new ideas about research, and it can be the basis for networking in and beyond the Network, so to speak.

Several supervisors who have posted Current Research Initiatives have offered to write more about their projects in the Newsletters. The following summary of original research by Dick Tibbits is the first of these offerings.  


2.     Report of Original Research by Network Member Dick Tibbits


--by Dick Tibbits, D.Min., CPE Supervisor at Florida Hospital, 616 East Rollins St., Suite 101, Orlando, FL 32803;

OBJECTIVE: To determine if patients with physician diagnosed stage-1 hypertension can achieve reductions in blood pressure and/or anger expression scores by participating in a forgiveness training program.

METHOD: Thirty-five qualifying participants were randomly divided into wait-listed control and intervention groups. The control group monitored blood pressure while the intervention group monitored blood pressure and participated in an 8-week forgiveness training program. After 8-weeks the wait-listed control became an intervention group. Both groups took the State-Trait Anger Expression Inventory test-2 pre and post intervention.

RESULTS: Those receiving forgiveness training had significant reductions in anger expression when compared to control group. While reductions in blood pressure were not achieved by all, a statistically significant correlation between anger expression reduction and blood pressure reduction was noted, suggesting that the higher one’s anger, the more effective forgiveness training may be in lowering blood pressure.

CONCLUSION: Given the multifactoral causes for hypertension, it would seem to be helpful to identify those hypertensive patients with elevated anger, to determine if they could benefit by forgiveness training to reduce anger expression and blood pressure. Forgiveness training may be an effective clinical intervention for some hypertensive patients with elevated levels of anger.


3.     Web Finds: Research-Based Presentations On Line 

CPE supervisors, students, and anyone working on research in the field of spirituality and health, should be aware of two web sites that offer on-line Powerpoint presentations from such important researchers and writers as David Larson, Harold Koenig, and Christina Puchalski.

The first site is that of the International Center for the Integration of Health and Spirituality (ICIHS)--the new name for the National Institute for Healthcare Research (NIHR). In fact the address remains [Correction, posted 8/26/03: the web site, which became in 2003, has been periodically inaccessible and may go off line in the near future because of the cessation of operations by the Center in August 2003.] This organization, with historic ties to the Templeton Foundation, has greatly encouraged research into the connections between spirituality and health and promoted the inclusion of spirituality in health care over the past decade. From their home page, click on Presentations, and there you will find four Powerpoint slide show presentations by the late David Larson on spirituality and cardiac issues, spirituality and suicide, and a two-part overview of the links between spirituality and health; and also a presentation by Harold Koenig on religion, aging, and healthcare in the 21st century.

The second site is that of the recently established George Washington Institute for Spirituality and Health (GWish), at This organization, located at the George Washington University Medical Center, is also associated with the Templeton Foundation, and the site offers information about various Templeton awards/grants. It also provides an extensive list of internet links concerning spirituality and health, a bibliography of print resources, and basic information about the FICA Spiritual History assessment that is copyrighted (1996) by Christina Puchalski [--for a more extensive presentation of the FICA Spiritual History, see: Puchalski, C. M. and Romer, A. L., "Taking a Spiritual History Allows Clinicians to Understand Patients More Fully," Journal of Palliative Medicine 3, no. 1 (Spring 2000): 129-37.] Dr. Puchalski offers a number of multimedia presentations on the site: e.g., "The Role of Spirituality in Health and Illness," and "Spirituality and End of Life Care: A Time for Listening and for Caring." See the Resources section of the site.]

As readers discover other important and useful resources on the web for research, please bring them to the attention of the ACPE Research Network.


4.     Student Guide I: Thinking Critically about Questionnaire Items

Pastoral care research most commonly elicits data by means of questions posed to subjects. These questions embody the overall concepts and intent of a study and are the foundation upon which the value of results rests. However, CPE students do not often seem to look critically at questionnaire items when reading studies, so the following guide was developed* to raise awareness and stimulate critical thinking in this area. [This resource is also available as a PDF by clicking here.]

Items on a research questionnaire can be problematic in many subtle ways. Below are examples pertaining to individual questions. However, questions can also play upon one another in sequence to create an overall effect, leading the responder or in some way skewing the data gained from the responses.

Social Expectation Bias --
Example: the question, "Do you believe in God?" may play into a bias in society that it is better to believe in God than not to, with the result being that responses may be skewed as some people simply give what they think may be the socially preferable answer. Multiple-choice formats can exacerbate this dynamic: in the case of asking subjects to agree or disagree with the statement, "I believe in God," there may be an especially strong inclination to avoid disagreement.
Compound Question Ambiguity --
Example: the question, "Do you believe that God hears your prayers and answers them?" is actually two questions, making a single answer potentially problematic.
Concept Ambiguity --
Example: in the question, "Do you believe in life after death?" the phrase life after death, may be commonplace, but it is theologically complex, encompassing a number of different ideas--an immediate "heaven" or an eventual "rapture," to name just two from Christian theology. And, if someone answered "yes," thinking of "living on only in the hearts and minds of loved ones," would this answer fit with the researcher's intention in asking the question? There may be some concept ambiguity in any question, but researchers should strive to ask questions that minimize this problem.
Cultural Concept Bias --
Example: while religiosity was for many years assessed by asking, "How often do you attend church?" the question is problematic for anyone for whom the word church is not culturally appropriate.
Unintentional (Implicit) Dogma --
Example: in the question, "Do you believe that God graciously answers prayers?" the word graciously is not only culturally rich but may be tied to a specific theology of grace. If such is not intended in the question, it may evoke more than a response that speaks precisely to the subject of the inquiry.
Unnecessary Add-Ons --
Example: in the question, "Do you believe that God is actively involved in His creation?" the word His potentially interjects issues of divine gender that could distract some responders. Unless such is the intention of the question, leaving out this add-on word would seem still to preserve the basic question.
Offensive Wording --
Example: in the question, "Do you believe in God?" the last word here could be taken with offense by responders who, for instance, believe it inappropriate to write out the name of the divine (--such as with the practice of many adherents of Judaism who write the divine name only as G-d [which is noted humbly by the writer of this guide as a further example of the complexity of language across lines of religious and cultural diversity]). Also, a lack of capitalization of words like God and Scripture, as well as pronouns with divine antecedents, is sometimes a source of offence in religious questionnaires. Offensive wording does not mean only scatological language, but any wording that produces such a strongly distracting response from the intent of a question.
Off-the-Mark Wording --
Example: in the question, "Do you believe in God?" the written word God may be acceptable yet so evidently off-the-mark as to be a distraction, for instance if this question was directed at Muslim subjects used to seeing the word Allah.
Jolting Language --
Example: in the question, "Do you believe that God helps even despicable people?" the word despicable seems over-the-top. Unless such jolting language is intentional, researchers should strive to construct questions that have an even flow in their reading.
Process Modality Mismatch --
Example: in the question, "What are, in order of importance, your five deepest feelings about God?" responders are asked to engage emotional material in an intellectual way (i.e., through prioritization). The process modality for answering this question may interfere with the responder's ability to engage the material: the responder may feel stretched in different directions, and in this case the likely result would be a response that muses about feelings rather than one that deeply represents them. Another--and common--example can be found in questions that pose abstract, hypothetical and conditional scenarios about emotionally sensitive issues, such as, "If you were told that you had only a month to live, do you think you would attend religious services more frequently?" Our human capacity to imagine the practical consequences of the condition set out in this question makes suspect the value of any response except as an indication of one's capacity itself to imagine the effects of being told that death was only a month away.
Inadequate Specificity --
Example: the question, "Is prayer important?" does not specify whether what is being asked concerns a personal, social, or essential quality of prayer. Just as some questions can be unintentionally exclusive, others can be too broad.
Intrusiveness Concerns --
Example: the question, "What do think has been your greatest sin?" probably touches too intimate a subject to expect frankness from a responder, even with precautions for confidentiality. An enduring difficulty in pastoral care research revolves around the intimate nature of people's spiritual lives. Even careful inquiry can seem intrusive to some.
Abstruse Wording --
Example: the question, "Do you believe that a transcendent entity affects you in the deepest of places?" may be a well-intentioned attempt to find the most inclusive language, but along the way the question may lose the responder through unfamiliar, poetic wording. Sometimes the limits of language cannot be practically avoided, and a more complex means of questioning (e.g., using multiple questions or including explanations of meanings) is necessary.
Reading Level: Vocabulary --
Example: in the question, "What's your understanding of your personal relationship to God?" there are two four-syllable words that may be beyond the reading level of many in the general population. In fact, the inclusion of a three-syllable word and a contraction may be problematic for some responders. The literacy of those who write questionnaires often blinds researchers of the many people who struggle to read at a sixth grade level. Researchers should, as a rule, choose the clearest and simplest possible wording in questionnaires (but never convey a tone of condescension).
Reading Level: Syntax --
Example: in the (ludicrous) question, "Do you, who, of course, may or may not believe in God, believe in heaven?" the problem with syntax is obvious, but researchers should in general be careful of qualifying clauses that may be intended to clarify but which nevertheless can be confusing. Diagramming sentences is a good test here: the further one moves from a simple subject, verb, and predicate the greater may be the risk of losing the responder.
Print Reading Issues: Font and Size --
A note here about printed questionnaires: fonts should be clear enough to be read by someone with poor, unaided vision--usually 14 point type is sufficient, and generally sans-serif fonts (like Helvetica) are easier to read than serif fonts (like Times).

*This guide was originally developed by John Ehman for use with CPE students at the University of Pennsylvania Health System in 2000. It may be printed directly or copied and pasted into a document. [E-mail notification of the use of this guide, and feedback about it, would be appreciated:] This is the first in a series of Student Guides. Supervisors and researchers who have developed such teaching tools are encouraged to send them in to be included in this series.


5.     Convener's Report

As part of the plan for publicizing the web site since September 2001, all past members of the Network have been contacted by e-mail or by letter, and all ACPE Supervisors (for whom the ACPE had a working address) have been individually e-mailed. The response has been encouraging. In our first three months, over 1,300 visits to the site have been counted (note the counter at the bottom of the pages). What is more, twenty individual/institutional memberships have been received along with one regional membership, and one student has already submitted application materials for a research award.

Feedback on our web site has ranged from appreciative to enthusiastic. Among the many comments received so far: "We have so needed the website," "The Article of the Month (which I have just checked out) will be immediately helpful," "I am very interested!" "Your site looks great and is now on my favorites list," "A clean, clear website and a useful service to the ACPE," "Much needed," and "I was very impressed." Several people commented on the value for students of an awareness of the research literature, and others noted the potential application of research to both the CPE curriculum and the educational evaluation process.

There have been no particular suggestions, however, concerning the future direction of the site. So, there are no plans currently to alter the basic format or type of content. While there was originally an intention to have a Members Only section for sensitive information, this has not seemed to be a pressing concern for members. Also, while a Discussion section might be useful, it too has not figured in any feedback, and its development is on hold. These issues, along with a general reevaluation of the site, might best be taken up in discussion at the next national conference meeting.

There have been two reports of difficulty accessing the site: one regarding the site as a whole and one regarding the Awards information section. The former complaint has been investigated but remains a mystery. The latter problem has uncovered a glitch in the Awards page for some Netscape Navigator users, and the page will be reformatted soon.

If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at .
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The ACPE Research Network. All rights reserved.